Fewer False Alarms: A Quality Improvement Proposal to Reduce Blood Culture Contamination in a Community Emergency Department
Student Name
Doctor of Nursing Practice Program, Aspen University
DNP860: Evidence-Based Practice for Quality Improvement
Instructor Name
Month Day, Year
Fewer False Alarms: A Quality Improvement Proposal to Reduce Blood Culture Contamination in a Community Emergency Department
This proposal brings together the problem definition, question, evidence, improvement model, and evaluation plan developed over the course into a single plan for leadership approval. It asks the emergency department and hospital leaders to support a nine-month improvement project, with modest supply costs, to reduce blood culture contamination and the unnecessary treatment it causes.
The Problem
Over the past year, 4.1 percent of the roughly 9,600 blood culture sets collected in our 48-bed emergency department grew skin organisms in only one set, the usual signature of contamination. Cultures drawn through newly placed intravenous catheters were contaminated more than twice as often as those drawn by separate venipuncture, and most cultures were drawn through catheters. Contaminated cultures lead to patient call-backs, repeat testing, unnecessary vancomycin, longer stays, and added laboratory work (Doern et al., 2019). Our rate exceeds the long-standing 3 percent benchmark.
The Question and the Evidence
The project asks whether a three-part collection bundle, separate venipuncture, sterile technique with a standardized kit, and diversion of the first portion of blood, reduces contamination compared with current practice in adult emergency department patients over six months. The appraised evidence supports each component. A systematic review found venipuncture and trained collectors reduced contamination (Snyder et al., 2012). A within-patient trial found contamination of 0.22 percent with a diversion device versus 1.78 percent without it, with no loss of true bacteremia detection (Rupp et al., 2017). An emergency department improvement study that made collection fully sterile reduced contamination from 4.3 to 1.7 percent (Self et al., 2013). No study tested all three together, which is why the bundle will be introduced in stages.
Aim
Bring contamination in emergency department cultures under 2 percent, from a starting point of 4.1, by the ninth month after the first test, and sustain it for 12 months after, without reducing the detection of true bloodstream infections or delaying antibiotics for suspected sepsis.
Improvement Approach and Plan
The project will use the Model for Improvement, testing each component through plan-do-study-act cycles that begin with a written prediction and small scale (Langley et al., 2009). Months 1 to 3: test separate venipuncture with two nurses on one shift, then expand by shift and pod, with a supply cart stocked for venipuncture at each pod. Months 3 to 6: add the sterile collection kit, with a brief hands-on training session and a two-person check at first use. Months 6 to 9: add the diversion device, beginning with a single pod. Each component spreads to the next shift or pod only when its process measure shows at least 80 percent use and the outcome is not worse. The team includes a DNP project lead, two staff nurse champions, the microbiology supervisor, an infection preventionist, an emergency physician, and the nurse manager as sponsor.
Evaluation
The contamination rate will be plotted weekly on a run chart for the team and monthly on a p-chart for leadership, with limits from the 12-month baseline and special cause rules fixed in advance. Process measures will track use of venipuncture, kits, and diversion. Balancing measures will track the true-positive rate, time from culture order to antibiotics for suspected sepsis, needle sticks per patient, and supply cost. Charts will be annotated with each change and with outside events. The decision about whether the bundle worked will be made by rules written before the first data point, not by the team's hopes.
Budget and Business Case
Direct costs are modest: sterile collection kits, estimated at $6 per set above current supplies; diversion devices, estimated at $10 per set once introduced; about 60 hours of staff time for training and team meetings; and no new equipment. For 9,600 sets a year, full use of both would add roughly $154,000 in annual supply cost. The savings come from avoided consequences of contamination. A decision analysis for an emergency department found routine use of a diversion device cost-beneficial, and showed that the higher a department's starting contamination rate and the longer the unnecessary antibiotic courses, the larger the savings (Skoglund et al., 2019). With our high baseline rate, the business case is favorable, and the finance department will validate it with our own data on admissions, vancomycin days, and repeat cultures linked to contaminated sets.
Ethics and Approval
The project is designed as quality improvement: its purpose is to improve care in this department, it uses practices supported by evidence, no patient is assigned to a group at random, and every data point already exists in routine laboratory records. A determination request will go to the hospital's review office, which decides whether a project counts as human subjects research; the expected answer is that it does not. No patient identifiers will leave the laboratory report, and results will be reported in aggregate.
Sustainability
If the aim is met, the bundle will be written into the emergency department's blood culture collection policy, added to nursing orientation and annual competencies, and built into the electronic documentation so that collection method is recorded for every set. The contamination rate will remain on the department's quality dashboard, reviewed monthly, with a rise above 2.5 percent for two consecutive months triggering review.
Risks and Mitigation
Three risks could undermine the project. Supply shortages of kits or devices during expansion would stall adoption; the nurse manager will set par levels with materials management before each stage. Nurse turnover could erode new habits; the bundle will be added to orientation from the first month, and champions on each shift will coach new staff. And a busy season, such as a winter respiratory surge, could make any added step feel impossible; the team will plan stages around the department's historical volume and accept a slower pace rather than force changes during peak weeks. Naming these risks in advance lets leaders see that the plan has been tested against the department's realities.
Conclusion
Blood culture contamination in our emergency department causes avoidable harm and cost at a rate above the traditional benchmark. The evidence supports a three-part collection bundle, the Model for Improvement provides a way to introduce it safely in stages, and the evaluation plan will show whether it works without causing harm. The proposal asks for modest resources in exchange for fewer false alarms for patients, clinicians, and the laboratory.
References
Doern, G. V., Carroll, K. C., Diekema, D. J., Garey, K. W., Rupp, M. E., Weinstein, M. P., & Sexton, D. J. (2019). Practical guidance for clinical microbiology laboratories: A comprehensive update on the problem of blood culture contamination and a discussion of methods for addressing the problem. Clinical Microbiology Reviews, 33(1), Article e00009-19. https://doi.org/10.1128/CMR.00009-19
Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.
Rupp, M. E., Cavalieri, R. J., Marolf, C., & Lyden, E. (2017). Reduction in blood culture contamination through use of initial specimen diversion device. Clinical Infectious Diseases, 65(2), 201-205. https://doi.org/10.1093/cid/cix304
Self, W. H., Speroff, T., Grijalva, C. G., McNaughton, C. D., Ashburn, J., Liu, D., Arbogast, P. G., Russ, S., Storrow, A. B., & Talbot, T. R. (2013). Reducing blood culture contamination in the emergency department: An interrupted time series quality improvement study. Academic Emergency Medicine, 20(1), 89-97. https://doi.org/10.1111/acem.12057
Skoglund, E., Dempsey, C. J., Chen, H., & Garey, K. W. (2019). Estimated clinical and economic impact through use of a novel blood collection device to reduce blood culture contamination in the emergency department: A cost-benefit analysis. Journal of Clinical Microbiology, 57(1), Article e01015-18. https://doi.org/10.1128/JCM.01015-18
Snyder, S. R., Favoretto, A. M., Baetz, R. A., Derzon, J. H., Madison, B. M., Mass, D., Shaw, C. S., Layfield, C. D., Christenson, R. H., & Liebow, E. B. (2012). Effectiveness of practices to reduce blood culture contamination: A Laboratory Medicine Best Practices systematic review and meta-analysis. Clinical Biochemistry, 45(13-14), 999-1011. https://doi.org/10.1016/j.clinbiochem.2012.06.007
How this DNP 860 Module 8 example is structured
DNP860 Module 8 typically assembles the modules into one defensible quality improvement proposal. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example restates the problem, question and evidence, sets a numeric aim, specifies the plan, evaluation, budget, ethics determination and sustainability, and closes with the request to leaders.
DNP860 Module 8 questions, answered
What does DNP860 Module 8 usually ask for?
The final module typically asks you to assemble the problem, PICOT question, evidence, improvement model, implementation plan and evaluation plan from earlier modules into one complete quality improvement proposal. Aspen does not publish module deliverables, so your classroom's instructions govern.
What should a QI proposal include beyond the evidence?
A numeric, time-bound aim, a staged implementation plan with a team, an evaluation plan with outcome, process and balancing measures, a budget and business case, an ethics determination and a plan for sustaining the change.
How can blood culture contamination be reduced?
Evidence supports separate venipuncture rather than drawing through new catheters, trained collectors, sterile collection technique and devices that divert the first portion of blood, which can carry skin contaminants.
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